Phillip is a young man born with hypoplastic left heart syndrome
referred to your practice for a range of mental health concerns. He
underwent palliation to an extracardiac Fontan in infancy and
experienced multiple complications over the next decade including
valvular regurgitation and arrhythmias necessitating a pacemaker.
Phillip continued to have systolic heart failure with New York Heart
Association class II symptoms, managed with 4 medications and
Despite this complex history, Phillip had intact cognitive
abilities, achieved typical milestones, and performed well academically
in secondary school. His first year of college proved to be more
challenging, and Phillip presented to the outpatient psychiatry service
with an acute depressive episode. His family history included
depression, without known attention-deficit/hyperactivity disorder
(ADHD). Treatment, including a selective serotonin reuptake inhibitor,
cognitive behavioral therapy, and family support, led to near resolution
of his symptoms of depression.
In subsequent appointments, Phillip described a long history
of inattention and disorganization with onset in childhood. This
contributed to the decision to leave college, despite remission of
symptoms of depression. Phillip was unable to study for any extended
period without “perfect conditions,” described as the absence of
potential distractions except for background music. Despite attempts to
maintain “perfect conditions,” Phillip was often off task and
“hyperfocusing” on irrelevant topics. Phillip struggled with planning
and time management and would misplace items daily. Moreover, although
the importance of self-care was well understood, Phillip often forgot to
take his cardiac medication or to exercise, and he admitted to
inconsistent sleep habits because of losing track of time.
Based on a comprehensive psychiatric evaluation including
retrospective report from a parent, Phillip was diagnosed with ADHD,
coexisting with major depressive disorder, in remission. Significant
ADHD symptoms were documented by interview, self-report, and
administration of an abbreviated neuropsychological battery.
Considering concerns regarding use of stimulants in a patient
with congenital heart disease, including death, stroke, and myocardial
infarction,1,2 how would you assess the risks-benefits of use of stimulants with Phillip?